TROPICAL DISEASES.

741 cause of endemic anaemia, and was only consider what steps might be taken for its eradication, the ancient Egyptians appeared to have had a correct knowledge of its etiology and to have adopted measures for its treatment and prophylaxis. According to Scheuthauer and Joachim the famous papyrus Ebers (1550 B.c.) rightly ascribed the disease to an intestinal worm, and von Oefele had pointed out that a connexion between the disease and the carrying and handling of sand was fully recognised. Might not the extraordinary veneration of the ancient Egyptians for the dung-beetle, the Ateuchus sacer of modern entomologists, be connected with the prophylaxis of ankylostomiasis and other infections spread by the means of contaminated faeces ? He made the suggestion merely as a matter of archaeological curiosity. They all knew what an important part the scarab played in the theogony of the banks of the Nile. This remarkable insect was represented on all the monuments of the Pharaohs from the great Delta to the very heart of Nubia ; it was carved of all dimensions and in every possible material more frequently than any other figure. Evidently the ancient Egyptians, perfectly cognisant of the benefit derived from this wonderful scavenger beetle, looked upon it as a tutelary god. That suggestion seemed to him more plausible than any of the fanciful reasons hitherto advanced to explain why they considered the dung-beetle as sacred. In support was the fact that other animals likewise had been consecrated by the Egyptians in order to protect and to preserve them on account of the beneficial action which they exercised in keeping down vermin. He need but mention the cat, the kestrel, the viper - natural enemies of the plague-conveying rat. In 1900, in the Roman Campagna, he had had the opportunity of studying the habits of the sacred dung-beetle, and he had been struck by the rapidity with which excreta, scarcely dropped, were cut up, formed into pellets, and buried deeply in the soil. It would be impossible to find a more perfect method of faecal disposal. Dr. C. W. DANIELS (London) stated that he did not think sufficient importance had been attached to the destructive action of certain dipterous larvae, particularly those of the sarcophagidas, which lived in the faeces till nearly mature He was and destroyed all thin-shelled entozoal eggs. not in favour of compulsion by government and thought that more could be done by quiet action on the part of the medical authorities than by active government action which might defeat its own ends. Dr. F. M. SANDWITH (London) said that he used to be an ardent exponent of the virtues of thymol, but the severe effects produced in some patients had caused him now for some years to prefer 3-naphthol or the combination of eucalvptol, chloroform, and castor oil. The important question of prophylaxis could be most easily and most cheaply met by preaching the doctrine of early burial of fasces in dry earth or sand. The ankylostoma eggs could not develop without moisture. Ankylostomiasis as an endemic disease should be treated as regards fascal disposal as they had learnt to treat epidemics of cholera and enteric fever. The PRESIDENT of the section said that Dr. Sambon had referred to the sanitary work of the ancient Egyptians ; he might also have referred to the better known sanitary laws of Moses. What did the Hebrew do when going to the field in the early morning. He had a"paddle upon his weapon"" and making a hole he buried and covered up his deposit therein. Thus were destroyed myriads of ankylostomes. The crux of the whole question, as Sir Patrick Manson had said, was fæcal disposal. He believed in education. If they got at the children in a generation they would have the adults. Sir PATRICK MANSON, in reply, said that he was glad to gather from what had been said that the section was quite in sympathy with his remarks on the desirability of an effort being made to mitigate the plague of ankylostomiasis in the tropics, and further that the method of attack should be directed towards fæcal sanitation. Dr. ROBERT T. LEIPER (London) stated that that very morning he had been able to examine, together with Dr. Sandwith, a supply of worms from an anaemic boy sent by Dr. T. L. Bancroft of North Queensland and that he had found both ankylostoma duodenale and necator Americanus. This record of the presence of both known forms in Australia was highly interesting and rounded off their information of the geographical distribution of the "American " form.

(Berlin) read a paper on lhe Diagnosis of Latent Malaria. He said that three phases might be distinguished, a first phase or "primary period of latency," lasting from the moment of infection to the first pyrexial attack and characterised by nervousness, dyspepsia, more or less anæmia, and the presence of basophilic granules in the erythrocytes; a second phase made up of " intermediate periods of latency " intervening between the single paroxysms and characterised by the presence of parasites, particles of pigment in the leucocytes, especially the large mononuclears, basophilic granules in the erythrocytes, and relative increase of the large mononuclears ; and finally a third phase, or ’’final period of latency," following the last recurrence of fever and not usually lasting over six months. He pointed out that the presence of urobilinuria might indicate the presence of latent malaria when all other signs were wanting. It was not a specific sign like the presence of gametes in the blood; it was merely a symptom of liver disturbance and might not Dr. A. PLEHN

apprehended the just beginning to

present in every case of malaria, but its presence after malarial fever and in the absence of any other cause which might explain the liver affection certainly proved that the malarial infection was not entirely spent. Dr. E. MARCHOUX (Paris) read a paper on Dysenteric Amœbæ and Liver Abscess. Sir PATRICK MANSON said that it was a matter of gratification to the Section of Tropical Diseases that men of the high standing of Dr. Plehn and Dr. Marchoux thought it worth their while to be present there and to take part in their work. Both of them had served a long apprenticeship in tropical pathology and had attained positions of special distinction The importance of in that department of medicine. recognising latent malaria was especially great in regard to Great Britain and her tropical possessions. Any method that would enable them to recognise when a man was the subject of latent malaria or when he was free from infection would be a welcome addition to practical medicine. The presence of basophilic granules in the erythrocytes was an unreliable test, for they occurred in many other infections, notably trypanosomiasis. With regard to the administration of quinine, those who had been in the habit of taking it as a prophylactic in tropical countries should continue its use for at least three months after their return to England and intermittingly for a further period of one to two years. He had many times seen the disregard of this practice culminate in attacks of blackwater fever, sometimes fatal. Dr. MALCOLM WATSON (Federated Malay States) read a few remarks on Rare Nervous Symptoms seen in Malarial Patients. Dr. SAMBON said that blackwater fever had been mentioned both by Dr. Plehn and Sir Patrick Manson in conjunction with malaria, and he seized the opportunity again to state most emphatically that blackwater fever was a disease entirely distinct from any of the known forms of malaria. Many years had passed since he first pointed out that blackwater fever was a specific disease more closely allied to the babesia infections of the lower animals and to yellow fever than to malaria. Now he was more than ever convinced of the correctness of his hypothesis, and information which he had been able to gather tended to show that the disease might be conveyed by the agency of ticks. FRIDAY, JULY 31ST. Dr. DANIELS opened a discussion on Lymphatic Diseases in the Tropics. He said that in practically all tropical diseases some implication of the lymphatic system did or might occur, whether the diseases were due to bacteria, protozoa, or metazoan parasites. In many the lymphatic condition was be

of diagnostic value, as it led to little or no direct ill effect. In many of the protozoal diseases enlargement of the glands might be met with. In trypanosomiasis the superficial glands, especially those of the neck, were early involved and were of great diagnostic value : not only could the enlarged glands be readily felt but trypanosomes were more readily found on gland puncture than in the peripheral blood. Cutaneous breaches of continuity from biting arthropoda, ticks, flies, mosquitoes, and the like, and in some places from leeches, were so frequent that naturally lymphangitis and adenitis were more common than in England. It was therefore of interest to notice that such

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742

frequent recurring attacks of lymphangitis were notChe acute lymphangitis was probably due to the introduction ordinarily attended by any general lymphatic obstruction. c)f bacteria. Manson believed that the adult worms under

The same might be said of the more chronic ulcerations, ccertain conditions aborting were the real cause of some cases with the exception of that due to the granuloma of the c)f obstruction. The aborted embryos instead ofbeing fully pudenda. In the latter disease the glands were not (mtstretched as when normally discharged were still coiled obviously enlarged, no secondary deposits took place, and i in their egg capsules which, according to the stage of yet chronic lymphatic obstruction occurred giving rise to levelopment, might be round or elliptical. Their shorterswelling of the penis, scrotum, or vulva, resembling ordinary (liameter being larger than the smallest lymphatic channels. tropical elephantiasis though rarely attaining any great size. 1 ova were stopped in the glands and blocked up all the With regard to lymphatic bacterial diseases the plague bubo .:anastomosing branches till there was complete obstruction. was the one most definitely associated with the tropics. Manson’s hypothesis had not received the full consideration in clinical the ambulant rare cases which it required. It seemed to have been condemned tacitly Closely resembling aspects of bubonic plague were the so-called climatic buboes. Inas too complicated and involving a whole series of supposithose, also, there was no evidence of lymphangitis, but the 1bions. On analysis, however, every point in the hypothesis. glands were enlarged and tender with some febrile disturb- rested on actual observations. It was more than plausible; ance, and in the few cases which he had seen there had beenit was a logical sequence that must almost necessarily definite suppuration. No plague bacilli were found. Thefollow and gave a complete explanation of the phenomena lymphatic diseases more especially associated v;ith tropicalobserved. conditions were those due to animal parasites. In many of Dr. W. T. PROUT (Liverpool) said that in Europeans a them the eggs were deposited, amongst other places, in the bubo which was called "malarial"or"climatic"was glands, and might, as in schistosoma Japonicum, be very occasionally found. As to the former he had seen no numerous. In such cases the glands were enlarged and evidence; as to the latter, there was undoubtedly a form of fibrotic, but there again no obstructive symptoms occurred. suppurative lymphadenitis for which there appeared to be In most tropical countries elephantiasis was common and no appreciable cause. The name given to this disease other evidences of lymphatic obstruction, such as chyluria, was only an expression of ignorance. He contended that, Much speculation as to the facts of geographical distribution were opposed to the theory were also fairly common. Causation of that condition had taken place. Lym- of relationship between elephantiasis and filariasis. In not confined to the was obstruction tropics; rare his opinion elephantiasis was a streptococcal disease. phatic Sir PATRICK MANSON was glad that Dr. Daniels had given cases occurred in England and were indistinguishable from tropical elephantiasis. Personally he had seen two cases. an accurate outline of his views, which were generally misHow was it that lymphatic obstruction sufficient to cause understood. He did not say that the hypothesis had been chronic cedema, a rare disease in’ England, in the tropics proved ; he recognised the propriety of an attitude of doubt might affect 5, 10, or 15 per cent. of the population ? They towards it, but not of denial. To his way of thinking it was knew that elephantiasis might occur from several causes, but a most probable explanation of the facts. Dr. SAMBON said that Dr. Daniels had very ably shown its frequency in the tropics claimed a special cause. The discovery of filaria Brancrofti in the lymphatics naturally that there was much evidence in favour of a relationship suggested a plausible hypothesis to account for this between tropical elephantiasis and filariasis. In Europe Filariae were common in the cases indistinguishable from tropical elephantiasis weredifference in frequency. tropics and unknown in temperate climates, as elephantiasis occasionally met with’; they were looked upon by some as was or nearly so. The connexion between filariasis and disproving any connexion between filariasis amd elephantiasis. elephantiasis was strongly indicated by identity of geo- in tropical countries. He was not going to discuss- the graphical, topographical, racial and sex distribution, and various causes which might bring about lymphatic obstruction was further supported by an exactly similar distribution of in Europe, but he wished to point out that a filarial preknown intermediate hosts. Thornhill in Ceylon had shown disposing cause was by no means excluded in European cases that in natives of Colombo filariasis and elephantiasis were of elephantiasis. Filaria Bancrofti had a very wide distrirare compared with certain places a few miles out. Low in bution and was certainly found on the African and Asiatiç the West Indies had proved that a definite ratio held good. coasts of the Mediterranean. Possibly it occurred also on In British Central Africa the relationship was very definite ; the European side. At any rate its occasional appearance in large tracts of the country there were no elephantiasis and there was more than probable ; indeed, a well-authenticated no filariasis. On the Shir6 highlands both filariasis and case had been described in 1894 by Dr. M. Font y Torné in elephantiasis were found only in immigrants. On the lower a Spaniard from Canet di Mar (Barcelona) who had never Shire river filariasis was common and elephantiasis occurred. left his country. That man suffered from chyluria and of the scrotum. His blood contained filaria Higher up the river neither was found. At the south end of Lake Nyassa he had found no elephantiasis, only one larvæ. There was no reason why filaria Bancrofti should person with filaria and scanty mosquitoes capable of not prosper in certain parts of Europe. They knew that transmitting the infection, whilst at the north end he innumerable species of filariæ lived in the mammals, birds, had observed fairly numerous cases of filaria, several and reptiles of Europe; some also in man, as, for cases of elephantiasis, and an abundance of suitable instance, filaria labialis, filaria conjunctivæ, and other mosquitoes. Observations of that kind could be multiplied ill-determined species. All these filariæ were fostered indefinitely. They all confirmed the relationship. The old and transmitted by arthropod intermediary hosts, which objection that cases of lymphatic obstruction were the might be flies, mosquitoes, or ticks, according to the species. cases in which fewer people harboured filarial embryos than Filaria immitis, thecruel filaria" of dogs, had a very the average population need not detain them. All it meant wide distribution in tropical and sub-tropical countries, but was that in lymphatic obstruction the embryos were not able it was found also in Northern Europe (France, Germany, to enter the circulation. How did the filaria lead to lymphatic Denmark, and England). Like filaria Bancrofti it was propaobstruction ? In the first place it caused thickening, gated by mosquitoes. Dr. J. L. MAXWELL (Formosa) pointed out that the island dilatation, and other changes in the wall of the channel ; occasionally it gave rise to hemorrhage. He had himself of Formosa was in practically the same latitude as Amoy on the mainland; the inhabitants were for the most part seen dilated masses of lymphatics, containing living filariæ, distended with recently coagulated blood. Again, suppura- Chinese immigrants from the Amoy region; the customs, tion with abscess formation might occur, either as a result habits, and diseases were with one exception exactly the of the death of the worm or in some way connected with same, that exception being the presence of filariasis and its presence, and in the contents of such abscesses remains elephantiasis as a very common disease in the Amoy region, of the worm had been found. Elephantiasis might occur as and the almost complete absence in Formosa of both diseases. a direct sequence of a single attack of acute inflammation or after repeated attacks of a similar nature, or gradually Captain J. W. D. MEGAW, I.M.S., stated the facts which He did he had observed in two districts in Bengal. In Puri, where without pain or any erysipelatoid attack. not think it necessary that all cases of elephantiasis! elephantiasis was common, in 100 prisoners whose blood was need be assumed to be produced in the same manner by the taken at night and examined filarial embryos were found in filaria. In some it might be haemorrhage, in other perhaps! 15. (Three of the prisoners suffered from elephantiasis ; in In Dinajpur, more common it was merely that the lymphatics distended none of these were filarial embryos found.) and altered by the niariae were more liable to inflammation. where elephantiasis was rare, in 50 prisoners taken at random

enlargement

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743 the blood taken at night showed no filarial embryos. (Nonehad been languishing for want of new facts. He disputed l Ruffer’s suggestion of infection per anum. prisoners in this jail [300 in number] suffered from Dr. Dr. SAMBON then moved a vote of thanks to the President elephantiasis.) Professor S. A. POWELL (Bombay) said that in manyifor the admirable manner in which he had conducted the Indian birds-owls, kites, &c.-filariæ were common in the Ibusiness of the section. lymphatics and subcutaneous tissues like filaria Bancrofti in man, but they did not find any elephantiasis so far as he was aware. He might add a few figures bearing on the relative incidence of filariasis and elephantiasis. In Cachar, where elephantiasis was rare except when imported, of 256 indigenous persons whose blood he had examined only one FROM showed filariæ. In Bombay, where elephantiasis was not THE 1830. uncommon, of 363 night bloods examined 18, about 5 per cent., showed filariæ. On the other hand, the families of seven cases of elephantiasis, 43 persons, showed no case of REMARKABLE CASE OF LONGEVITY. filariasis. That filariæ produced inflammation was unthe AT meeting of the Medico-physical Society of Florence, doubted. The phenomena of inflammation had been oftenon the 13th of December, Dr. Buzzi related the case of a studied in the cornea of the rabbit. In the swampy districtsEemale of his acquaintance, who at that time was 94 years of India nature often gave them a beautiful demonstrationf age, and in the history of whose life there were some ,in the case of filaria in the eye of the horse. He had oftenrather curious circumstances. Her family had been remarkwatched the course of the disease. A white worm aboutable for her father died in his 106th year, her longevity; one and a half inches long was suddenly seen in the anterior grandfather, by her father’s side, in his 109th year, and her chamber of the horse’s eye, darting about like a miniaturemother’s father in his 89th year ; the latter had, even at his eel in an aquarium; usually the aqueous humor and corneaold The age, been remarkable for his bodily strength. remained quite clear for about 48 hours, then both became woman herself had been rather a delicate she was child, steamy, iritis set in, and in four days’ time the cornea was married in her fifteenth year; in the third month of dead white and opaque unless the worm had been removed. her marriage she menstruated for the first time, and Professor A. CASTELLANI (Ceylon) described a palliative in the fourth she became pregnant; in five years she treatment of elephantiasis by means of thiosinamin or fibro- had borne three children. At this period her husband died, lysin injections and methodical bandaging, followed by and she became soon afterwards subject to hysterics, removal of portions of the redundant skin when most of the which it is stated were most effectually obviated by violent fibrous tissue had been absorbed. she was passionately fond of dancing, hunting, exertion ; The PRESIDENTof the section disputed Manson’s theory and riding on horseback, and frequently, when heated, threw of elephantiasis. The anatomical arrangement of the herself into a river or a cold bath. This mode of life brought lymphatics-as to distribution and valvular mechanism- on violent headache, which with slight intermissions conthe ova from from one side of the to prevented passing body tinued to her 40th year, when it yielded to the abrasion of the other and the theory demanded the presence of an the hair; it always returned, however, as soon as the hair aborting female in many and various parts to account for the had grown to about two inches in length. In other respects, clinical fact that the disease in the scrotum was usually she was in perfect health, in very good spirits, and of most symmetrical. After complete removal of a scrotal tumour extraordinary appetite, in which she also fully indulged; there was no return of the trouble, although the so-called three chickens, or from five to six pounds of roast meat, and "obstruction" remained. But a recurrence would surely oranges or peaches, were just sufficient for her breakfollow if the least amount of unhealthy tissue remained in twenty fast. In her 45th year, her eldest son (who at the time of the penis or perineum. This showed that the disease was in the report was 77 years old, and in the full enjoyment of health) parts removed and not in those that were left. He spoke at received, in battle, a wound in the left breast, and the fright length of treatment. which this accident caused, produced, strangely enough, a Dr. NATTAN-LARRIER described some interesting cases of hæmorrhage from her left breast; the discharge was not sleeping sickness with nervous and mental symptoms. but continued for two years. Her menses had Dr. DANIELS then replied. With regard to the symmetrical copious, been rather always scanty, and she had frequently been ,condition of the scrotal affection he said that that was common to various haemorrhages. In her 53rd year menstruasubject to all conditions where the loose cellular subcutaneous tissues tion ceased, but reappeared eight months afterwards, and of the scrotum were involved. The non-infection of other continued regularly to her 94th year, which is the age she members of families he had observed in British Guiana with had attained at the time of the report. She is rather of ’regard to filariasis. Frequently one member only of a family small stature, but of very robust frame, and possesses was infected. A person with elephantiasis having no the full use of all her senses; she sleeps only five ,embryos in his peripheral blood was not so likely to infect hours, gets up at day-break, and takes a walk of other members of the family as a person with niariae and several hours; her manner of life is extremely simple, and ’without lymphatic obstruction. her appetite is rather strong, her meals are frugal, though Mrs. BoNTE SHELDON ELGOOD (Cairo) read a paper on especially if compared with what she formerly had been used Bilharziosis among Women and Girls in Egypt. to. She sleeps an hour after dinner,. the rest of the day she It showed that the disease was common in young girls, is continually engaged, being employed either in domestic ,even in those who did not bathe and who used filtered water affairs or reading ; she walks very much, and so quick, that only. Town children were frequently affected. Bilharziosis sometimes young people are scarcely able to follow her. Six was rare in adult women who might, however, have suffered years ago she met with an accident and broke both arms, but from it in youth. European women and girls were not was perfectly cured within four weeks. At present she is in known to suffer from it, though in the towns they drank and perfect health ; at night only she has sometimes slight washed in water from the same source as natives used. attacks of dyspnoea and agitation ; when they occur, she Water, however, was not stored in European households. gets up and opens. the window; the fit then generally Infection was probably not due mainly to bathing, as subsides, if not, she goes out into the open air, and after had been suggested. It was possibly due to faulty storage of about half an hour’s walk, feels perfectly well again.-Ann. drinking water or to the eating of raw vegetables and fruit di Med. Fase. di Maggio e Giugno, 1830, page 595. washed in dirty canals or rivers. Dr. M. ARMAND RUFFER (Ramleh, Egypt) said that he THE BRITISH ASSOCIATION.—Since the prowas of opinion that women in early life were as much infected as were men. Infection might be due to ablutions and was visional programme of the Chemistry Section of the British Association was announced the following additional papers possibly rectal. Dr. SANDWITH said that Dr. Ruffer’s suggestion would have been promised: (1) the Liquefaction of Helium, by hardly explain the prevalence of bilharziosis in the English Professor Dr. Kamerlingh Onnes; (2) Anticipations and soldiers in South Africa. Experiments on the Liquefaction of Helium, by Sir James Sir PATRICK MANSON said that Mrs. Elgood had made a Dewar ; and (3) Note on a Volatile Compound of Cobalt most important contribution towards the solution of the with Carbon Monoxide, by Dr. Ludwig Mond and others. problem of the etiotogy of bilharziosis which for many years These communications are awaited with great interest. of the

Looking Back.

LANCET, SATURDAY, Sept. 4th,

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